Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

HC SOM ANTI-DIURETIC HORMONE

Facility

$80.00

Service Code	CPT 84588 90
Hospital Charge Code	900911035
Hospital Revenue Code	301
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$48.00
Rate for Payer: Aetna of CA Government/Medicare	$48.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Smart Auto/Commercial	$48.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$48.00
Rate for Payer: LLUH Dept of Risk Management WC	$44.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.00

HC SOM ANTI-DIURETIC HORMONE

Facility

$80.00

Service Code	CPT 84588
Hospital Charge Code	900911035
Hospital Revenue Code	301
Min. Negotiated Rate	$44.00
Max. Negotiated Rate	$64.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna of CA HMO/PPO	$64.00
Rate for Payer: Health Smart Auto/Commercial	$48.00
Rate for Payer: LLUH Dept of Risk Management WC	$44.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$60.00

HC SOM ANTI-GBM TITER AB

Facility

$26.00

Service Code	CPT 83516 90
Hospital Charge Code	900911188
Hospital Revenue Code	301
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$20.80
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna of CA HMO/PPO	$20.80
Rate for Payer: Health Smart Auto/Commercial	$15.60
Rate for Payer: LLUH Dept of Risk Management WC	$14.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.50

HC SOM ANTI-GBM TITER AB

Facility

$26.00

Service Code	CPT 83516
Hospital Charge Code	900911188
Hospital Revenue Code	301
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$19.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.60
Rate for Payer: Aetna of CA Government/Medicare	$15.60
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Smart Auto/Commercial	$15.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.60
Rate for Payer: LLUH Dept of Risk Management WC	$14.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.50

HC SOM ANTI-GBM TITER AB

Facility

$26.00

Service Code	CPT 83516 90
Hospital Charge Code	900911188
Hospital Revenue Code	301
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$19.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.60
Rate for Payer: Aetna of CA Government/Medicare	$15.60
Rate for Payer: Cash Price	$11.70
Rate for Payer: Health Smart Auto/Commercial	$15.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.60
Rate for Payer: LLUH Dept of Risk Management WC	$14.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.50

HC SOM ANTI-GBM TITER AB

Facility

$26.00

Service Code	CPT 83516
Hospital Charge Code	900911188
Hospital Revenue Code	301
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$20.80
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna of CA HMO/PPO	$20.80
Rate for Payer: Health Smart Auto/Commercial	$15.60
Rate for Payer: LLUH Dept of Risk Management WC	$14.30
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$19.50

HC SOM ANTI-LIVERKIDNEY MICROSOMAL AB

Facility

$21.76

Service Code	CPT 86376
Hospital Charge Code	900911453
Hospital Revenue Code	302
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$16.32
Rate for Payer: Health Smart Auto/Commercial	$13.06
Rate for Payer: Cash Price	$9.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.06
Rate for Payer: Aetna of CA Government/Medicare	$13.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.06
Rate for Payer: LLUH Dept of Risk Management WC	$11.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.32

HC SOM ANTI-LIVERKIDNEY MICROSOMAL AB

Facility

$21.76

Service Code	CPT 86376
Hospital Charge Code	900911453
Hospital Revenue Code	302
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$17.41
Rate for Payer: Cash Price	$9.79
Rate for Payer: Cigna of CA HMO/PPO	$17.41
Rate for Payer: Health Smart Auto/Commercial	$13.06
Rate for Payer: LLUH Dept of Risk Management WC	$11.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.32

HC SOM ANTI-LIVERKIDNEY MICROSOMAL AB

Facility

$21.76

Service Code	CPT 86376 90
Hospital Charge Code	900911453
Hospital Revenue Code	302
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$17.41
Rate for Payer: Cash Price	$9.79
Rate for Payer: Cigna of CA HMO/PPO	$17.41
Rate for Payer: Health Smart Auto/Commercial	$13.06
Rate for Payer: LLUH Dept of Risk Management WC	$11.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.32

HC SOM ANTI-LIVERKIDNEY MICROSOMAL AB

Facility

$21.76

Service Code	CPT 86376 90
Hospital Charge Code	900911453
Hospital Revenue Code	302
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$16.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.06
Rate for Payer: Aetna of CA Government/Medicare	$13.06
Rate for Payer: Cash Price	$9.79
Rate for Payer: Health Smart Auto/Commercial	$13.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.06
Rate for Payer: LLUH Dept of Risk Management WC	$11.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.32

HC SOM ANTIMULLERIAN HORMONE, S

Facility

$55.00

Service Code	CPT 83520 90
Hospital Charge Code	900912908
Hospital Revenue Code	302
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$41.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.00
Rate for Payer: Aetna of CA Government/Medicare	$33.00
Rate for Payer: Cash Price	$24.75
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.25

HC SOM ANTIMULLERIAN HORMONE, S

Facility

$55.00

Service Code	CPT 83520
Hospital Charge Code	900912908
Hospital Revenue Code	302
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$41.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.00
Rate for Payer: Aetna of CA Government/Medicare	$33.00
Rate for Payer: Cash Price	$24.75
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.25

HC SOM ANTIMULLERIAN HORMONE, S

Facility

$55.00

Service Code	CPT 83520 90
Hospital Charge Code	900912908
Hospital Revenue Code	302
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$44.00
Rate for Payer: Cash Price	$24.75
Rate for Payer: Cigna of CA HMO/PPO	$44.00
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.25

HC SOM ANTIMULLERIAN HORMONE, S

Facility

$55.00

Service Code	CPT 83520
Hospital Charge Code	900912908
Hospital Revenue Code	302
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$44.00
Rate for Payer: Cash Price	$24.75
Rate for Payer: Cigna of CA HMO/PPO	$44.00
Rate for Payer: Health Smart Auto/Commercial	$33.00
Rate for Payer: LLUH Dept of Risk Management WC	$30.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$41.25

HC SOM ANTI-NEUTROPHIL AB

Facility

$68.00

Service Code	CPT 86021
Hospital Charge Code	900911211
Hospital Revenue Code	302
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$54.40
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna of CA HMO/PPO	$54.40
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC SOM ANTI-NEUTROPHIL AB

Facility

$68.00

Service Code	CPT 86021 90
Hospital Charge Code	900911211
Hospital Revenue Code	302
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.80
Rate for Payer: Aetna of CA Government/Medicare	$40.80
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC SOM ANTI-NEUTROPHIL AB

Facility

$68.00

Service Code	CPT 86021 90
Hospital Charge Code	900911211
Hospital Revenue Code	302
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$54.40
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna of CA HMO/PPO	$54.40
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC SOM ANTI-NEUTROPHIL AB

Facility

$68.00

Service Code	CPT 86021
Hospital Charge Code	900911211
Hospital Revenue Code	302
Min. Negotiated Rate	$37.40
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$40.80
Rate for Payer: Aetna of CA Government/Medicare	$40.80
Rate for Payer: Cash Price	$30.60
Rate for Payer: Health Smart Auto/Commercial	$40.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$40.80
Rate for Payer: LLUH Dept of Risk Management WC	$37.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$51.00

HC SOM ANTI-NEUTROPHIL CYTOPLASM ANTI

Facility

$23.15

Service Code	CPT 86255
Hospital Charge Code	900910287
Hospital Revenue Code	302
Min. Negotiated Rate	$12.73
Max. Negotiated Rate	$18.52
Rate for Payer: Cash Price	$10.42
Rate for Payer: Cigna of CA HMO/PPO	$18.52
Rate for Payer: Health Smart Auto/Commercial	$13.89
Rate for Payer: LLUH Dept of Risk Management WC	$12.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.36

HC SOM ANTI-NEUTROPHIL CYTOPLASM ANTI

Facility

$23.15

Service Code	CPT 86255 90
Hospital Charge Code	900910287
Hospital Revenue Code	302
Min. Negotiated Rate	$12.73
Max. Negotiated Rate	$17.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.89
Rate for Payer: Aetna of CA Government/Medicare	$13.89
Rate for Payer: Cash Price	$10.42
Rate for Payer: Health Smart Auto/Commercial	$13.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.89
Rate for Payer: LLUH Dept of Risk Management WC	$12.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.36

HC SOM ANTI-NEUTROPHIL CYTOPLASM ANTI

Facility

$23.15

Service Code	CPT 86255 90
Hospital Charge Code	900910287
Hospital Revenue Code	302
Min. Negotiated Rate	$12.73
Max. Negotiated Rate	$18.52
Rate for Payer: Cash Price	$10.42
Rate for Payer: Cigna of CA HMO/PPO	$18.52
Rate for Payer: Health Smart Auto/Commercial	$13.89
Rate for Payer: LLUH Dept of Risk Management WC	$12.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.36

HC SOM ANTI-NEUTROPHIL CYTOPLASM ANTI

Facility

$23.15

Service Code	CPT 86255
Hospital Charge Code	900910287
Hospital Revenue Code	302
Min. Negotiated Rate	$12.73
Max. Negotiated Rate	$17.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.89
Rate for Payer: Aetna of CA Government/Medicare	$13.89
Rate for Payer: Cash Price	$10.42
Rate for Payer: Health Smart Auto/Commercial	$13.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.89
Rate for Payer: LLUH Dept of Risk Management WC	$12.73
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.36

HC SOM ANTINUCLEAR AB,HEP-2 SUB,S

Facility

$10.00

Service Code	CPT 86039 90
Hospital Charge Code	900912903
Hospital Revenue Code	302
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$7.50
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.00
Rate for Payer: Aetna of CA Government/Medicare	$6.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.50

HC SOM ANTINUCLEAR AB,HEP-2 SUB,S

Facility

$10.00

Service Code	CPT 86039
Hospital Charge Code	900912903
Hospital Revenue Code	302
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$7.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.00
Rate for Payer: Aetna of CA Government/Medicare	$6.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.50

HC SOM ANTINUCLEAR AB,HEP-2 SUB,S

Facility

$10.00

Service Code	CPT 86039 90
Hospital Charge Code	900912903
Hospital Revenue Code	302
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$8.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna of CA HMO/PPO	$8.00
Rate for Payer: Health Smart Auto/Commercial	$6.00
Rate for Payer: LLUH Dept of Risk Management WC	$5.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.50

Know your out-of-pocket cost for care.

All Charges